Audits of Medicare Plus Blue^SM PPO automatic implantable cardiac defibrillator claims have begun

HMS (formerly Health Data Insights), an independent company working for Blue Cross Blue Shield of Michigan, started auditing Medicare Plus Blue^SM PPO automatic implantable cardiac defibrillator claims on Aug. 1, 2017. These audits will:

• Include a two-year look-back at claims.
• Check patient-met criteria for automatic implantable cardiac defibrillator insertion.
• Detect, prevent and correct waste and abuse.
• Facilitate correct claim payment.

Be prepared to share medical charts for review. After an audit, HMS will send you a letter with findings and information on how to request an appeal, if necessary.

Medical criteria information
To meet Centers for Medicare & Medicaid Services criteria for an implantable automatic defibrillator, a patient must not have had:

• An enzyme-positive myocardial within the past 40 days
• A coronary artery bypass graft or percutaneous transluminal coronary angioplasty within the past three months

HMS reviews inpatient and outpatient-reimbursed claims for procedures involving insertion of these devices within the waiting periods, or time frames, indicated above. If a review of the medical record confirms that the procedure occurred within those time frames, HMS will tag all costs associated with the procedure as an overpayment.

Questions?

• Contact your Blue Cross provider consultant.
• During an audit, if you need to speak to an HMS vendor representative, call 1-866-875-1749.